RHIT EXAM PREP TEST QUESTIONS WITH WELL DETAILED SOLUTIONS- INFO TO PREP
FOR RHIT EXAM BASED ON ISBN-13: 978-0763756611
One essential item on Physical exam
General appearance as assessed by MD (Chief complaint, ROS & Family Hx - medical Hx
provided by the pt)
Elements of which data set do I collect if I'm a trauma registrar?
DEEDs (Data Elements for EDs) - recommended data set for hospital-based EDs
Data set for Acute Care hospitals
UHDDS (Uniform Hospital Data Set) - required data set for Acute Care hospitals
Data set for LTC
MDS (Minimum Data Set) - required data set for LTCs
ORYX
An initiative of TJC that implements 5 core measures to improve safety and quality of health
care.
5 core measures of ORYX
,CHF. AMI. Pneumonia (CAP). Each has requirements, e.g. ASA at arrival & DC, beta-
blockers, blood culture, smoking cessation advice, etc. ORYX has more core measure sets.
A hospital chooses the set according to the type of pts it treats (can be one core & rest non-
core)
Quantitative vs Qualitative analysis of MRs
Quantitative - check presence or absence of necessary sigs, reports
vs
Qualitative - check documentation consistency, e.g. compare pt's Rx profile to MAR.
Quality of documentation NOT clinical care
Index with Unique Identifier codes
Physician index - not real MDs name, but codes. To protect MDs identity
POMR
Problem Oriented MR. Helps index documentation throughout MR
H&P time standard to meet TJC & CoP requirements
24 hrs after admission or prior to surgery
DC summary records
Significant findings during hospitalization
,Time frame and copies of recent H&P per TJC
Copies of recent H&P done in MD's office is allowed in lieu of admission H&P as long as the
interval note (interval changes) are present upon admission
When can Interval note replace H&P upon admission?
1) If pt is re-admitted within 30 days for the same problem & copy of recent H&P is
available;
2) If copy of recent H&P done in MD's office is available upon admission
Indices in hospital
1) MPI - cross-reference of pt's name & MR number;
2) Disease index - a listing in diagnostic code number order (I can use it to get stats on # of
a Dz cases);
3) Physician index - a listing of cases in order by MD's name or number;
4) Operation index - a listing of operations performed
Most serious delinquencies
1) H&P;
2) Operative report;
Formal release of pt from hospital is
, DC order. If DC order is missing - pt is assumed to leave AMA
Who can accept VOs?
Persons designated by hospital's P&Ps and State & Federal laws
When is problem list required?
On 3rd visit
RHIO
Regional Health Information Organization - network allowing providers to access pts MRs
Info on MR supplied by a pt
Health Hx, CC & ROS - all subjective
Data comprehensiveness
Presence of all required data elements
CARF
Commission on Accreditation of Rehab Facilities
FOR RHIT EXAM BASED ON ISBN-13: 978-0763756611
One essential item on Physical exam
General appearance as assessed by MD (Chief complaint, ROS & Family Hx - medical Hx
provided by the pt)
Elements of which data set do I collect if I'm a trauma registrar?
DEEDs (Data Elements for EDs) - recommended data set for hospital-based EDs
Data set for Acute Care hospitals
UHDDS (Uniform Hospital Data Set) - required data set for Acute Care hospitals
Data set for LTC
MDS (Minimum Data Set) - required data set for LTCs
ORYX
An initiative of TJC that implements 5 core measures to improve safety and quality of health
care.
5 core measures of ORYX
,CHF. AMI. Pneumonia (CAP). Each has requirements, e.g. ASA at arrival & DC, beta-
blockers, blood culture, smoking cessation advice, etc. ORYX has more core measure sets.
A hospital chooses the set according to the type of pts it treats (can be one core & rest non-
core)
Quantitative vs Qualitative analysis of MRs
Quantitative - check presence or absence of necessary sigs, reports
vs
Qualitative - check documentation consistency, e.g. compare pt's Rx profile to MAR.
Quality of documentation NOT clinical care
Index with Unique Identifier codes
Physician index - not real MDs name, but codes. To protect MDs identity
POMR
Problem Oriented MR. Helps index documentation throughout MR
H&P time standard to meet TJC & CoP requirements
24 hrs after admission or prior to surgery
DC summary records
Significant findings during hospitalization
,Time frame and copies of recent H&P per TJC
Copies of recent H&P done in MD's office is allowed in lieu of admission H&P as long as the
interval note (interval changes) are present upon admission
When can Interval note replace H&P upon admission?
1) If pt is re-admitted within 30 days for the same problem & copy of recent H&P is
available;
2) If copy of recent H&P done in MD's office is available upon admission
Indices in hospital
1) MPI - cross-reference of pt's name & MR number;
2) Disease index - a listing in diagnostic code number order (I can use it to get stats on # of
a Dz cases);
3) Physician index - a listing of cases in order by MD's name or number;
4) Operation index - a listing of operations performed
Most serious delinquencies
1) H&P;
2) Operative report;
Formal release of pt from hospital is
, DC order. If DC order is missing - pt is assumed to leave AMA
Who can accept VOs?
Persons designated by hospital's P&Ps and State & Federal laws
When is problem list required?
On 3rd visit
RHIO
Regional Health Information Organization - network allowing providers to access pts MRs
Info on MR supplied by a pt
Health Hx, CC & ROS - all subjective
Data comprehensiveness
Presence of all required data elements
CARF
Commission on Accreditation of Rehab Facilities
